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Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/ or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women:: If you are pregnant, or attempting to become pregnant, do not dive.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.
Yes
No
2. I am over 45 years of age.
Yes
No
3. I struggle to do moderate exercise (e.g., walk 1 mile in 14 mins or swim 200 meters without resting) or have been unable to do normal physical activities due to fitness or health reasons in the past 12 months.
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.
Yes
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.
Yes
No
7. I am currently undergoing (or have needed within 5 years) treatment for psychological issues, personality disorder, panic attacks, or addiction to drugs/alcohol; or I have been diagnosed with a learning or developmental disability.
Yes
No
8. I have had back problems, hernia, ulcers, or diabetes.
Yes
No
9. I have had stomach or intestine problems, including recent diarrhea.
Yes
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).
Yes
No

Participant Signature

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions

Date
Birthdate

If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval.

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